No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Spotlight on Surgical Techniques. Current Concepts in Arthroscopic Rotator Cuff Repair
Abstract
The interest in arthroscopic rotator cuff repair has increased exponentially over the last 5 years. Although the operative technique of repair continues to evolve, there are now several studies reporting excellent results after arthroscopic repair of rotator cuff tears. In this review, we focus on new concepts and techniques related to arthroscopic rotator cuff repair that have been recently introduced.
... tung und Akzeptanz der Schulterarthroskopie erfolgten schließlich erste Studien , die gute postoperative Ergebnisse nach rein arthroskopischer Rotatorenmanschettenrekonstruktion nachweisen konnten [12]. Es liegen heute zahlreiche wissenschaftliche Arbeiten vor, die das postoperative Ergebnis der verschiedenen Operationstechniken (offen, miniopen oder arthroskopisch) anhand von klinischen Scores, körperlicher Untersuchung und bildgebender Verfahren untersucht haben. ...
Rotatorenmanschettenrupturen zählen zu den häufigsten, degenerativen Sehnenerkrankungen. Beim jüngeren Patienten können sie als traumatische Verletzung auftreten, in der Mehrzahl der Fälle sind sie jedoch als multifaktorielle und schließlich degenerative Erkrankung des Sehnengewebes zu sehen. Hauptsymptom der Manschettenruptur sind Schmerzen und ein funktionelles Defizit der Schulter. Voraussetzung für eine weiterführende bildgebende Diagnostik ist die klinische Untersuchung und Funktionstestung, die zur Formulierung der Verdachtsdiagnose führt. Ein verminderter akromiohumeraler Abstand in der konventionell-radiologischen a.– p. Aufnahme gilt als indirekter Hinweis auf eine Ruptur der Rotatorenmanschette und, bei einem Wert von unter 7 mm, als starker, negativer prognostischer Faktor. Heute ist die Kernspintomografie der diagnostische Goldstandard. Sie hat eine hohe Sensitivität und erlaubt zusätzlich die Mitbeurteilung muskulärer fettiger Atrophie sowie Begleitpathologien. Mit konservativen Therapiemaßnahmen, wie Analgesie, manueller Therapie und krankengymnastische Beübung können eine signifikante Reduktion der Schmerzen und eine Verbesserung des aktiven Bewegungsumfangs erreicht werden. Operativ wird heute zumeist arthroskopisch vorgegangen, und die Sehne mithilfe von Fadenankern anatomisch refixiert. Die operative Therapie führt in aktuellen Studien zu einer signifikanten Verbesserung der Funktion, Schmerzreduktion und hoher Patientenzufriedenheit. Um den operativen Therapieerfolg nach Rekonstruktion sicherzustellen, ist eine stufenweise Nachbehandlung mit initialer Lagerung auf einem Schulterabduktionskissen, kontinuierlicher Bewegungstherapie und schrittweiser Aufbelastung notwendig.
... The concept of functional repair was first introduced by Burkhart and colleagues in the early 1990's [2,161718. The authors proposed that partial repairs would restore the force couple of the humeral head and increase acromion-humeral distance, resulting in dramatic changes in pain and function16171819. Consistent reports of successful results of partial repairs is promising but the failure to demonstrate superiority of complete repair over partial repair in the limited literature might be due to lack of statistical power in studies that have used small sample sizes of patients [13]. ...
Background
The literature has shown good results with partial repairs of large and massive tears of rotator cuff but the role of factors that affect reparability is less clear. The purpose of this study was twofold, 1) to examine clinical outcomes following complete or partial repair of large or massive full-thickness rotator cuff tear, and 2) to explore the value of clinical and surgical factors in predicting reparability.
Methods
This was a secondary data analysis of consecutive patients with large or massive rotator cuff tear who required surgical treatment (arthroscopic complete or partial repair) and were followed up for two years. Disability measures included the American Shoulder and Elbow Surgeons (ASES), the relative Constant-Murley score (CMS) and the shortened version of the Western Ontario Rotator Cuff Index (ShortWORC). The relationship between predictors and reparability was examined through logistic regressions and chi-square statistics as appropriate. Within group change over time and between group differences in disability outcomes, range of motion and strength were examined by student’s T-tests and non-parametric statistics.
Results
One hundred and twenty two patients (41 women, 81 men, mean age 64, SD = 9) were included in the analysis. There were 86 large (39 fully reparable, 47 partially reparable) and 36 (10 fully reparable, 26 partially reparable) massive tears. Reparability was not associated with age, sex, or pre-operative active flexion or abduction (p > 0.05) but the fully reparable tear group showed a better pre-operative ASES score (p = 0.01) and better active external rotation in neutral (p = 0.01). Reparability was associated with tear shape (p < 0.0001), size (p = 0.002), and tendon quality (p < 0.0001).
Conclusions
Reparability of large or massive tears is affected by a number of clinical and surgical factors. Patients whose tears could not be fully repaired showed a statistically significant improvement in range of motion, strength and disability at 2 years, although they had slightly inferior results compared to those with complete repairs.
... From the perspective of attaching engineering materials, results suggest that stresses associated with interfaces can be reduced by a biomimetic grading of elastic moduli even in cases for where no free boundary exists, for instance in the attachment of a fibrous composite component to a metallic pin (Genin and Hutchinson, 1999). From the perspective of surgical reattachment of the rotator cuff of the humeral head, results indicate that current surgical procedures, which excise transitional tissue prior to direct suturing of tendon to bone (Burkhart and Lo, 2006), might introduce higher stress concentrations into the repaired insertion site. Results further indicate that uniform scar tissue developing post-surgery, regardless of its mechanical properties, cannot return stress concentrations to physiologic levels. ...
The attachment of tendon to bone, one of the greatest interfacial material mismatches in nature, presents an anomaly from the perspective of interfacial engineering. Deleterious stress concentrations arising at bi-material interfaces can be reduced in engineering practice by smooth interpolation of composition, microstructure, and mechanical properties. However, following normal development, the rotator cuff tendon-to-bone "insertion site" presents an interfacial zone that is more compliant than either tendon or bone. This compliant zone is not regenerated following healing, and its absence may account for the poor outcomes observed following both natural and post-surgical healing of insertion sites such as those at the rotator cuff of the shoulder. Here, we present results of numerical simulations which provide a rationale for such a seemingly illogical yet effective interfacial system. Through numerical optimization of a mathematical model of an insertion site, we show that stress concentrations can be reduced by a biomimetic grading of material properties. Our results suggest a new approach to functional grading for minimization of stress concentrations at interfaces.
... 3). Lo and Burkhart described a morphological classification of RCTs based on arthroscopic observations 72 . The authors classified RCTs into four categories: crescent-shaped, U-shaped, L-shaped, and massive, contracted and immobile tears (Fig.1). ...
Rotator cuff tears are common and are a frequent source of shoulder pain and disability. A wide variation in the prevalence of rotator cuff tears has been reported. The etiology of rotator cuff tear remains multifactorial and attempts to unify intrinsic and extrinsic theories tried to explain the etiopathogenesis of rotator cuff tears. Knowledge of the etiopathogenesis of rotator cuff tears is important to improve our therapies, surgical techniques and promote tendon repair. Several strategies have been proposed to enhance tendon healing and recently research has focused on regenerative therapies, such as Growth Factors (GFs) and Plasma Rich Platelet (PRP), with high expectations of success.
An irreparable rotator cuff tear is a challenging condition to treat, and various treatment modalities are being introduced. Medialization in the partial repair method has the limitation of exposing the tuberosity, while tension-free biologic interposition tuberoplasty using acellular dermal matrix has the limitation of exposing the humeral head. The authors believe that by combining these two techniques, it is possible to complement each other's limitations. Therefore, they propose a surgical method that combines medialization and biologic interposition tuberoplasty for addressing these constraints.
This chapter reviews basic principles and techniques of arthroscopic suture passage and knot tying. The authors also review basics types of instrumentation and different types of arthroscopic knots.
Objective:
To review the research progress of arthroscopic long head of biceps tendon (LHBT) transposition in treatment of irreparable massive rotator cuff tears.
Methods:
The domestic and foreign related literature in recent years on the treatment of irreparable massive rotator cuff tears with different LHBT transposition methods under arthroscopy was reviewed and analyzed.
Results:
Arthroscopic LHBT transposition is an effective method for irreparable massive rotator cuff tears, which mainly includes "proximal cut", "both two cuts", "distal cut", and "no cut". Different methods of LHBT transposition can achieve good effectiveness, but its long-term effectiveness needs further follow-up.
Conclusion:
Arthroscopic LHBT transposition in treatment of irreparable massive rotator cuff tears is simple and effective. The patients can recover quickly after operation with less injury. But the technique has higher requirements for surgeons, and the indications must be strictly controlled.
Purpose
To systematically review the literature to 1) describe arthroscopic subscapularis repair constructs and outcomes in patients with isolated and combined subscapularis tears and 2) compare outcomes following single and double row subscapularis repair in both of these settings.
Methods
A systematic review was performed using PRISMA guidelines. PubMed, SCOPUS, and Cochrane Central Register of Controlled Trials were searched for Level I-IV evidence studies that investigated outcomes after arthroscopic subscapularis repair for the treatment of isolated subscapularis tears or subscapularis tears combined with posterosuperior rotator cuff tears in adult human patients. Data recorded included study demographics, repair construct, shoulder-specific outcome measures, and subscapularis re-tears. Study methodological quality was analyzed using the MINORS score. Heterogeneity and low levels of evidence precluded meta-analysis.
Results
The initial search yielded 811 articles (318 duplicates, 493 screened, 67 full-text review). Forty-three articles (2,406 shoulders, 57% males, mean age range 42 to 67.5 years, mean MINORS score 13.4 + 4.1) were included and analyzed. Articles reported on patients with isolated subscapularis tears (n = 15), combined tears (n = 17), or both (n = 11). The majority of subscapularis repairs utilized single-row constructs (89.4% of isolated tears, 88.9% of combined tears). All except for one study reporting on outcome measures found clinically significant improvements after subscapularis repair, and no clinically significant differences were detected in five studies comparing isolated to combined tears. Subscapularis re-tear rates ranged from 0% to 17% for isolated tears and 0% to 32% for combined subscapularis and posterosuperior rotator cuff tears. Outcomes and re-tear rates were similar in studies comparing single-row to double-row repair for isolated and combined subscapularis tears (p > 0.05 for all).
Conclusion
Arthroscopic subscapularis repair resulted in significant improvements across all outcome measures, regardless if tears were isolated or combined or if repairs were single or double row.
Background
Vitamin B 12 (Vit B 12 ) deficiency results in elevated homocysteine levels and interference with collagen cross-linking, which may affect tendon integrity. The purpose of this study was to investigate whether serum Vit B 12 levels were correlated with degenerative rotator cuff (RC) tear.
Methods
Eighty-seven consecutive patients with or without degenerative RC tear were enrolled as study participants. Possible risk factors (age, sex, medical history, bone mineral density, and serum chemistries including glucose, magnesium, calcium, phosphorus, zinc, homocysteine, Vitamin D, Vit B 12 , homocysteine, and folate) were assessed. Significant variables were selected based on the results of univariate analyses, and a logistic regression model (backward elimination) was constructed to predict the presence of degenerative RC tear.
Results
In the univariate analysis, the group of patients with degenerative RC tear had a mean concentration of 528.4 pg/mL Vit B 12 , which was significantly lower than the healthy control group (627.1 pg/mL). Logistic regression analysis using Vit B 12 as an independent variable revealed that Vit B 12 concentrations were significantly correlated with degenerative RC tear ( p = 0.044). However, Vit B 12 levels were not associated with tear size.
Conclusion
Low serum levels of Vit B 12 were independently related to degenerative RC tear. Further investigations are warranted to determine if Vit B 12 supplementation can decrease the risk of this condition.
Anterior cable reconstruction (ACR) using the long head of the biceps tendon (LHBT) was developed to place at the native superior capsule attachment site for large to massive rotator cuff tears (LMRCTs) with anterior cable disruption. In this study, we investigated whether ACR for reinforcement before ARCR prevented retear after arthroscopic rotator cuff repair (ARCR), especially in cases of LMRCTs with anterior cable disruption. A total of 125 patients who underwent arthroscopic rotator cuff repair (ARCR) for LMRCTs were retrospectively enrolled. To assess the benefit of ACR with LHBT, all data were compared with those after ARCR alone. As a result, ACR with LHBT showed satisfactory clinical and radiologic outcomes in comparison with conventional ARCR only technique. ACR with LHBT prevented retear after ARCR and improved the AHD, although There was no difference of clinical outcomes between two groups.
Background
Lack of physical therapists has led to increment of self-managed rehabilitations in post-arthroscopic rotator cuff repair (ARCR) in the forms of booklets or leaflets.
Purpose
The aim of study is to investigate 1) the acceptance of post-ARCR patients towards an education booklet, and 2) whether it could be a timesaving and laborsaving tool to physical therapists.
Methods
An education booklet was established through a systematic review. Patients who underwent ARCR in our hospital were included and randomly assigned to the intervention or control group (27 women, 21 men, mean age=57.06 years old). Patients in the intervention group received educational booklets, and an evaluation was also obtained after they finished reading. Patients’ understanding of the booklet was determined by asking patients to re-enact training presented in the booklet. Then, a therapist blinded to allocations would personally demonstrate training to patients until patients fully understood the protocol. For the control group, the same therapist coached patients until the whole protocol was clearly understood. The coaching time for patients in both groups was recorded.
Results
Out of 48 patients, 24 (50%) were randomly assigned to the intervention group, and 21 (87.50%) completed their questionnaire. Out of these 21 patients, 20 (95.24%) rated the booklet as “excellent and easy to read”, and 17 (80.95%) felt that the booklet was helpful. The re-enaction accuracy was for strengthening training and specific training (71.43% and 61.90%, respectively). As compared to the control group, the time of coaching for the patients to fully master the protocol in the intervention group was significantly less (P<0.01).
Conclusion
Patients highly applauded this booklet, and they cherished the information and support it contained. Nevertheless, the re-enaction accuracy was not high, suggesting that the high level of acceptance does not guarantee full understanding of information sent to patients.
Rotator cuff disease is common and the diagnosis of impingement syndromes requires all available information, including history, physical examination, and imaging. A commonly used classification scheme of the various shoulder impingement syndromes is to divide them based on those where the pathogenesis resides outside the glenohumeral joint capsule (termed external impingement) and those residing inside the glenohumeral joint capsule (termed internal impingement). External impingement syndromes include subacromial impingement and subcoracoid impingement. Internal impingement syndromes include posterosuperior impingement, which belongs in the spectrum of abnormalities leading to the disabled throwing shoulder, and anterosuperior impingement. Each impingement syndrome is a distinct entity, often affecting different demographics of patients, but more than one type of impingement syndrome may be seen in an individual. This chapter (1) summarizes our current knowledge of the anatomy of the structures related to impingement, including the rotator cuff and biceps pulley; (2) reviews the multi-modality imaging manifestations of rotator cuff disease and the various impingement syndromes; and (3) reviews the expected and abnormal appearances of the rotator cuff after surgical therapy.
Rotator cuff tendons undergo degeneration with age, which could have an impact on tear propagation. The objective of this study was to predict tear propagation for different levels of tissue degeneration using an experimentally validated finite element model of a supraspinatus tendon. It was hypothesized that greater amounts of degeneration will result in tear propagation at lower loads than tendons with less degeneration. Using a previously-validated computational model of supraspinatus tendon, 1-cm tears were introduced in the anterior, middle, and posterior thirds of the tendon. Cohesive elements were assigned subject-specific failure properties to model tear propagation, and tendon degeneration ranging from “minimal” to “severe” was modeled by modifying its mechanical properties. Tears in tendons with severe degeneration required the smallest loads to propagate (122–207 N). Posterior tears required greater loads compared to middle and anterior tears at all levels of degeneration. Stress and strain required for tear propagation decreased substantially with degeneration, ranging from 8.5 MPa and 32.6% strain for minimal degeneration and 0.6 MPa and 4.5% strain for severe degeneration. Overall, this work indicates that greater amounts of tendon degeneration lead to greater risk of tear propagation, supporting the need for early detection and treatment of rotator cuff tears.
Massive rotator cuff tears constitute 10% to 40% of rotator cuff tears. Surgical repair is challenging, with high retear rates (20% to 90%). The aim of this study was to develop a new surgical technique to perform an interpositional expanded polytetrafluoroethylene (ePTFE) patch repair for massive and/or irreparable rotator cuff tears that minimizes arthroscopic knot tying without compromising repair strength. (1) Twelve 30×50 mm ePTFE patches and no.2 sutures (450 mm length) were either sterilized in an autoclave for 15 minutes at 130°C and 120 kPa, or left unsterilized. The sutures and patches were then pulled to failure in an Instron Materials Testing System to verify the effect of sterilization on the biomechnical properties. (2) A “Slide and Grip” technique was developed for synthetic patch interpositional repair and compared with our standard “Weave” technique. Autoclaving had no effect on patches (486±15 N vs. 491±15 N; mean±SEM) or sutures. Both “Weave” and “Slide and Grip” techniques had similar repair strengths (279±22 vs. 248±15 N). However, the “Slide and Grip” technique was much faster to perform than the (12.3±1.0; vs. 21.5±1.0 min; mean±SEM) (P<0.0001). A novel technique for the ePTFE patch repair of massive rotator cuff tears provided 40% reduction in operative time with similar pullout strength compared with the “Weave” technique.
Economic pressure highlights the critical need for appropriate diagnosis and treatment of various shoulder pathologies since under-diagnosis and under-treatment can result in increased costs to society in the form of disability and lost production. On the other hand, aggressive over-treatment can further inflate already burgeoning health-care costs and potentially harm the patient. Therefore, it is crucial to distinguish the indications between operative and nonoperative management, especially in common shoulder pathologies such as rotator cuff tears, anterior shoulder instability, biceps tendinitis, lesions to the acromioclavicular joint, and proximal humeral fractures. As a result, a detailed analysis of individual risk factors for potential failures should be performed and treatment should be based on individualized care with consideration given to each patient’s particular injury pattern, functional demands, and long-term goals.
Superior capsular reconstruction (SCR) of the shoulder has recently gained popularity as an option for joint-preserving shoulder surgery for patients with an irreparable rotator cuff tear. In the absence of glenohumeral arthritis, rotator cuff tear irreparability should only be diagnosed for most patients after a careful diagnostic arthroscopy. Superior capsular reconstruction adds biological, passive, superior constraint to the glenohumeral joint, thereby optimizing the rotator cuff force couples and improving joint kinematics. At short-term follow-up, SCR has been shown to be effective for pain relief and restoration of active shoulder motion, even in the worst cases of shoulder dysfunction (true shoulder pseudoparalysis). The rapid early adoption and expansion of SCR is justified by its excellent anatomical, biomechanical, and short-term clinical results. The techniques for arthroscopic SCR using dermal allograft continue to improve; however, the operation remains technically demanding. Patients with risk factors for irreparability and who might benefit from reconstruction of the superior capsule should be counseled about the operation as an additional, joint-preserving procedure that can be done in conjunction with arthroscopic, partial rotator cuff repair.
Rotator cuff tears have been noted in the setting of shoulder instability, particularly in older patients (Porcellini et al., Sports Med Arthrosc 19:395–400, 2011). Anterior glenohumeral instability in young athletes has also been associated with tears of the rotator cuff (Savoie et al., Orthop Clin North Am 32:457–461, ix, 2001; Goldberg et al., Br J Sports Med 37:179–181, 2003). Efforts to understand rotator cuff pathomechanics have shown relationships between various anatomic lesions and glenohumeral instability (Gombera and Sekiya, Clin Orthop Res 472:2448–2456, 2014). Craig (Craig, Clin Orthop Res (190):212–216, 1984) popularized the idea that failure of an attenuated posterior rotator cuff occurs in older patients, with relative sparing of the anterior capsule and labrum. The failure of the infraspinatus to restrain anterior humeral head translation may lead to anterior instability. This posterior mechanism of anterior dislocation is in contrast to the more common mechanism seen in younger patients, in which anterior capsular and labral structures fail, with the rotator cuff uninjured.
Background:
The anterior rotator cable is critical in force transmission of the rotator cuff. However, few clinical studies have examined the correlation between the integrity of the anterior supraspinatus tendon and surgical outcomes in patients with rotator cuff tears.
Purpose:
To compare the clinical and structural outcomes of the arthroscopic repair of full-thickness rotator cuff tears with and without anterior disruption of the supraspinatus tendon.
Study design:
Cohort study; Level of evidence, 3.
Methods:
One hundred eighty-one shoulders available for magnetic resonance imaging (MRI) at least 6 months after arthroscopic rotator cuff repair, with a minimum 1-year follow-up, were enrolled. The anterior attachment of the rotator cable was disrupted in 113 shoulders (group A) and intact in 68 shoulders (group B). The mean age at the time of surgery in groups A and B was 59.6 and 59.2 years, respectively, and the mean follow-up period was 24.2 and 25.1 months, respectively.
Results:
There were statistically significant differences in the preoperative tear size and pattern and muscle fatty degeneration between the 2 groups ( P = .004, P = .008, and P < .001, respectively). At final follow-up, the mean visual analog scale (VAS) for pain score during motion was 1.31 ± 0.98 and 1.24 ± 0.90 in groups A and B, respectively ( P = .587). The mean Constant score was 77.5 ± 11.2 and 78.0 ± 11.9 points in groups A and B, respectively ( P = .875). The mean University of California, Los Angeles score was 30.5 ± 4.1 and 31.0 ± 3.0 points in groups A and B, respectively ( P = .652). In assessing the repair integrity on postoperative MRI, the retear rate was 23.9% and 14.7% in groups A and B, respectively ( P = .029).
Conclusion:
Irrespective of involvement in the anterior attachment of the rotator cable, the mean 24-month follow-up demonstrated excellent pain relief and improvement in the ability to perform activities of daily living after arthroscopic rotator cuff repair. However, tears with anterior disruption of the rotator cable showed a significantly larger and more complex tear pattern and more advanced fatty degeneration. Additionally, the retear rate was significantly higher in patients with a tear involving the anterior attachment of the rotator cable.
In den letzten 5 Jahren gab es eine rasante Entwicklung arthroskopischer Techniken und Instrumente für die Rekonstruktion der Rotatorenmanschette sowie eine zum Teil neue Betrachtungsweise der Rotatorenmanschettenfunktion und deren Pathologie. Es wurde gezeigt, dass für ein gutes Ergebnis nicht, wie lange angenommen, immer ein wasserdichter Verschluss notwendig ist, sondern v. a. die Wiederherstellung der Kräftegleichgewichte in allen Ebenen. Durch die arthroskopischen Techniken ist eine Beurteilung und Behandlung der Manschette von nahezu jeder Richtung möglich. Danach lassen sich die meisten Rotatorenmanschettenläsionen in 4 Hauptgruppen einteilen, die dann einem Behandlungspfad entsprechend rekonstruiert werden können. Ein aktueller Diskussionspunkt ist die optimal geeignete Nahttechnik zur arthroskopischen Rekonstruktion. Neben einer hohen Reißfestigkeit soll eine möglichst große Auflagefläche auf dem Knochen erreicht, dabei aber die Durchblutung der Sehne nicht komprimittiert werden. Aufgrund dieser Erkenntnisse und Entwicklungen sind wir heute in der Lage, fast alle Rupturen, bis hin zur retrahierten Massenruptur, mit guten klinischen Resultaten rein arthroskopisch zu behandeln.
RESUMEN Introducción: Se han descripto numerosas clasificaciones de rupturas del manguito rotador. Ninguna de ellas ha logrado unificar conceptos acerca del tipo de lesión, pronóstico y tratamiento. El objetivo del siguiente trabajo es validar la reproductibilidad y fiabilidad de la clasificación propuesta por davidson y burkhart. Materiales y métodos: Corte transversal retrospectivo de la fiabilidad y reproductibilidad de la clasificación geométrica de rupturas del manguito rotador. Un total de 76 pacientes fueron analizados. Se incluyeron ruptura de espesor completo con rmn realizada en hospital italiano de buenos aires. Tres observadores con diferentes niveles de experiencia (residente, fellow y medico de planta) independientemente clasificaron los estudios en dos oportunidades con un intervalo de 4 semanas. Resultados: El acuerdo total inter-observador para los tres observadores fue 85.1% Con un valor de kappa de 0.951 (95% Ic: 0.94-0.97). El valor mas alto de fiabilidad fue alcanzado por el fellow con un valor de kappa de 0.875 (Ds ±0.047) Mientras que el score más bajo fue registrado por el residente con una puntuación de 0.815 (Sd ±0.56). De acuerdo a la guía de fleiss o de landis y koch todos los observadores alcanzaron excelente/casi perfecto acuerdo. Conclusión: La clasificación geométrica es comprensible y de fácil aplicación más allá del nivel de experiencia de los evaluadores. Se trata de una herramienta útil para comunicarse con excelentes resultados de fiabilidad y reproductibilidad intra e inter-observador. Tipo de estudio: Serie de casos. Nivel de evidencia: IV Palabras clave: Clasificación Geométrica; Rupturas del Manguito Rotador; Concordancia Intra e Interobservador SUMMARY Purpose: In 2010, james davidson and stephen burkhart proposed the geometric classification of rotator cuff tears: a system linking tear pattern to treatment and prognosis. The objective of this study is to validate by measuring the intra-examiner and inter-examiner reproducibility and reliability of the geometrical classification. Methods: This is a retrospective cross-sectional assessment of the reproducibility and reliability of a new rotator cuff tears classification. A total of 76 patients with full thickness rotator cuff tears on preoperative mri were analyzed. Three observers independently evaluated the mri according to the geometrical classification. The observers had different levels of experience and were represented by one resident, one medical fellow and one consultant of the arthroscopy and arthroplasty shoulder section. The mri's were review by the observers in two occasions with 4 weeks interval to evaluate the intra-observer reliability. Results: The overall inter-observer agreement was 85.1% Representing a kappa value of 0.951 (95% Ci: 0.94-0.97). The highest inter-observer agreement was found between the resident and the consultant with 88.2% Producing a kappa value of 0.954 (95% Ci: 0.92-0.97). The highest average intra-observer reliability was achieved by the fellow with a kappa value of 0.875 (Sd ±0.047). The resident, fellow and consultant reached an excellent/almost perfect agreement. Conclusion: The geometrical classification is comprehensive and easy applicable despite the level of experience of the raters. It is suspect as a very useful tool to communicate among orthopedic surgeons with excellent inter and intra-observer reproducibility. Type of study: Case series. Retrospective. Level of evidence: IV INTRODUCCIÓN Se han descripto numerosas clasificaciones para describir a las rupturas del manguito rotador. Algunos autores utili-zaron criterios morfológicos diferenciando las rupturas en transversas, verticales o retraídas. 1 Otros utilizaron la mayor longitud del diámetro de la ruptura para clasificarlas en lesiones pequeñas. Medianas, largas o masivas. 2 Por ul-timo otros autores caracterizaron las rupturas del mangui-to rotador según el número de tendones afectados. 3,4 Si repasamos la historia múltiples intentos se han hecho con el objetivo de agrupar las lesiones y establecer un pro-nóstico respecto a estas, pero ninguna de ellas lo ha logra-do. Podemos observar que las clasificaciones previamente mencionadas son incompletas o presentan puntos débiles. No relacionan ni sirven de guía el patrón de lesión que presenta preoperatoriamente con el tratamiento llevado a cabo. Muchas de ellas fueron descriptas en la era pre-resonancia magnética nuclear por lo cual son descripcio-nes basadas en una dimensión y no toman las ventajas que aporta hoy en día una RMN con información en tres di-mensiones. Por ultimo ninguna de las clasificaciones que se han descripto informa el pronóstico de la lesión luego del tratamiento. En el 2005 James Davidson y Stephen Burkhart 5 pro
L'arthroscopie d'épaule est un moyen fiable et validé de réparation de la coiffe des rotateurs. Elle est moins traumatisante pour le patient et permet une analyse plus fine de la rupture et des lésions associées.
Objective
Regain shoulder function and freedom of pain through arthroscopic fixation of the torn rotator cuff using anchors and tension bands.
Indications
Indications have increased these recent years, with the tremendous technical progress of arthroscopic surgeons. They are:1.
Isolated full-tendon rupture of the supraspinatus.
2.
All full-tendon tears of the supraspinatus, the infraspinatus or the teres minor, in cases of moderate retraction.
3.
Incomplete tears affecting the superior part of the subscapularis, either isolated or associated with a rupture of the supraspinatus.
4.
For lesions of the long head of the biceps: tenodesis for patients <60 years of age or for manual workers; tenotomy in all other instances.
Contra-indications
Fatty infiltration of infraspinatus and subscapularis of stages 3 and 4.
Frozen shoulder in the active phase.
Narrowing of the subacromial space (<7 mm).
Relative contra-indications: Patients ≥65 years.
Surgical Technique
Subacromial bursoscopy and glenohumeral arthroscopy.
Repair of the tendons using a posterior portal and an inside-out anterior portal, associated with one or two additional anterolateral portals.
Attachment with a single row or double row anchors.
Tenotomy/tenodesis of long head of biceps, if indicated.
Multiple etiologies have been implicated in the pathogenesis of rotator cuff tear mainly of two types: extrinsic, such as subacromial and internal impingement, tensile overload, repetitive stress; intrinsic, such as poor vascularity, alterations in material properties, matrix composition, and aging. The work of Yamamoto [1] statistically identified that the risk factors associated with rotator cuff tears in the general population were a history of trauma, the dominant arm, and age. In subjects who were under 49 years of age, rotator cuff tears were more strongly associated with the dominant arm and a history of trauma. These results indicated that extrinsic factors were more closely associated in the tears of the younger patients. The same study found 6.7 % of patients in their 40s with rotator cuff ruptures, 12.8 % in their 50s, 25.6 % in their 60s, 45.8 % in their 70s, and 50.0 % in their 80s, with the prevalence increasing with age. Despite these results, 16.9 % of the subjects without symptoms have also a rotator cuff rupture. © 2012 ESSKA Executive Office Luxembourg Centre Médical - FNM 76, rue d'Eich 1460 Luxembourg LUXEMBOURG. All rights are reserved.
Arthroscopic partial repair is a treatment option in irreparable large-to-massive rotator cuff tears without arthritic changes. However, there are indications that arthroscopic partial repair does not yield satisfactory outcomes.
To report the clinical and radiographic results of arthroscopic partial repairs in patients with irreparable large-to-massive cuff tears. In addition, an analysis was performed regarding preoperative factors that may influence patient outcomes and patient-rated satisfaction over time.
Case series; Level of evidence, 4.
From 2005 to 2011, a total of 31 patients who underwent arthroscopic partial repair for irreparable large-to-massive cuff tears were retrospectively evaluated. Partial repair was defined as posterior cuff tissue repair with or without subscapularis tendon repair to restore the transverse force couple of the cuff. Pain visual analog scale (PVAS), questionnaire results (American Shoulder and Elbow Surgeons [ASES] and Simple Shoulder Test [SST]), and radiographic changes (acromiohumeral distance and degenerative change) were assessed preoperatively, at first follow-up (roughly 1 year postoperatively), and at final follow-up (>2 years postoperatively). Patients rated their satisfaction level at each postoperative follow-up as well. Preoperative factors that might influence outcomes, such as patient demographics, tear size, and fatty infiltration, were investigated.
The preoperative, first follow-up, and final follow-up results for mean PVAS (5.13, 2.13, and 3.16, respectively) and questionnaires (ASES: 41.97, 76.37, and 73.78; SST: 3.61, 6.33, and 6.07, respectively) improved significantly (all P < .05). Radiographic evaluation showed no difference compared with preoperative status. Nevertheless, patient-rated satisfaction at final evaluation was inferior: 16 good responses ("very satisfied" and "satisfied") and 15 poor responses ("rather the same" and "dissatisfied"). Despite initial improvements in both groups (P < .05), patients with poor satisfaction demonstrated statistically significant deterioration in mean PVAS (from 2.07 to 4.67), questionnaire scores (ASES: from 74.56 to 59.80; SST: from 5.11 to 3.81), and acromiohumeral distance (from 7.19 to 5.06 mm) between the first and final follow-up (all P < .05). Patients with good satisfaction showed no significant difference or they improved (P > .05) from the first to the final follow-up. Among preoperative factors, fatty infiltration of the teres minor was identified as the only statistically significant factor affecting patient-rated satisfaction (P = .007).
This study showed that arthroscopic partial repair may produce initial improvement in selected outcomes at 2-year follow-up. However, about half of the patients in the study were not satisfied with their outcomes, which had deteriorated over time. Preoperative fatty infiltration of the teres minor was the only factor that correlated with worse final outcomes and poor satisfaction after arthroscopic partial repair.
© 2015 The Author(s).
Purpose of review: Arthroscopic rotator cuff repair has evolved from a theoretical possibility to reality. The purpose of this review is to highlight the most recent clinical studies of arthroscopic rotator cuff repair, illustrate technical aspects of repair of the massive tear, review the results of arthroscopic subscapularis repair, and discuss latest fixation techniques. Recent findings: Results of arthroscopic rotator cuff repair mirror those of open and mini-open techniques. As evaluation of cuff tears, appreciation of the patterns, mobilization techniques, and fixation techniques improve, even the most difficult tears will possibly be amenable to treatment by this technique. Summary: The medium term follow up of arthroscopic rotator cuff tears suggests that the results mirror those of open and mini-open techniques. The arthroscopic techniques can be used to address massive cuff pathology, subscapularis pathology, as well as supraspinatus injuries. Mobilization techniques have evolved to the point where the experienced arthroscopist can successfully address the spectrum of rotator cuff injuries successfully.
Coracoplasty has become a more commonly performed surgical procedure, as coracoid impingement has become increasingly recognized as a cause of persistent anterior shoulder pain. Open and arthroscopic techniques have shown satisfactory results. This article will provide a current review about the indications and techniques for coracoplasy, including both arthroscopic and open techniques and the expected outcomes.
Rotator cuff disease is common and may be clinically silent or a cause of shoulder pain. Evaluation of the rotator cuff before and after surgery is challenging for the orthopedic surgeon, but the radiologist can make an accurate diagnosis and facilitate appropriate management. This article reviews the current concepts on imaging diagnosis of rotator cuff disease, beginning with a discussion of the complex anatomy of the rotator cuff, continuing into the normal and pathologic MR imaging appearances of the rotator cuff including tendinosis and tearing, and concluding with a review of the postoperative cuff after various surgical repair techniques.
Objective
to analyze the results from arthroscopic suturing of large and extensive rotator cuff injuries, according to the patient's degree of osteopenia.
Method
138 patients who underwent arthroscopic suturing of large and extensive rotator cuff injuries between 2003 and 2011 were analyzed. Those operated from October 2008 onwards formed a prospective cohort, while the remainder formed a retrospective cohort. Also from October 2008 onwards, bone densitometry evaluation was requested at the time of the surgical treatment. For the patients operated before this date, densitometry examinations performed up to two years before or after the surgical treatment were investigated. The patients were divided into three groups. Those with osteoporosis formed group 1 (n = 16); those with osteopenia, group 2 (n = 33); and normal individuals, group 3 (n = 55).
Results
in analyzing the University of California at Los Angeles (UCLA) scores of group 3 and comparing them with group 2, no statistically significant difference was seen (p = 0.070). Analysis on group 3 in comparison with group 1 showed a statistically significant difference (p = 0.027).
Conclusion
the results from arthroscopic suturing of large and extensive rotator cuff injuries seem to be influenced by the patient's bone mineral density, as assessed using bone densitometry.
Rotator cuff tears are a significant clinical problem. Tears in the anterior supraspinatus might behave differently compared to central tears due to differences in regional structural properties. The objective of this study was to determine strain distributions for anterior supraspinatus tendon tears and the relationship to tear propagation during cyclic loading. It was hypothesized that highest maximum principal strain would be posterior to the tear, and tears would propagate in the direction of the maximum principal strain. Eight human cadaveric supraspinatus tendons with surgically created small tears in the anterior third were tested with increasing levels of cyclic loads. The position of strain markers was recorded on the bursal surface of the tendon to calculate strain. Tendons reached a 2 cm critical tendon retraction at 580 ± 181 N. Largest strains were found medial and posterior to the tear (26.1 ± 9.4%). In five tendons, the strain direction for the initial (114 ± 28°) and final loading sets (86 ± 20°) indicated the strain direction shifted from an anterior to posterior orientation (p < 0.01), corresponding to the direction of tear propagation. Based on the results, anterior supraspinatus tears would remain isolated to the supraspinatus tendon during activities of daily living. © 2014 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res
OBJECTIVE
: To evaluate the use of epinephrine in arthroscopic infusion serum as a measure to improve the quality of surgical viewing during procedures for treating rotator cuff tears.
METHODS:
This was a prospective randomized double-blind comparative study in which 49 arthroscopic repair procedures on rotator cuff tears were evaluated. Patients presenting ASA I and II surgical risk were included. The patients were placed into two groups: the first with epinephrine (1 mg/L) in the infusion serum and the second with pure physiological solution. A single surgeon was responsible for the procedures, without knowledge of the medication usage. The surgeon rated his quality of viewing during the operation, on an increasing scale from 0 to 10. Interscalene block or suprascapular nerve block was chosen randomly and used in association with general anesthesia. The anesthetist issued final report relating to possible intercurrences.
RESULTS:
The group with epinephrine received an average score of 9.29 and the group without epinephrine received an average score of 7.16. The difference was statistically significant (p < 0.05). There was no important clinical alteration relating to use of this drug.
CONCLUSION:
As well as being safe, addition of epinephrine at a concentration of 1 mg/L to the infusion serum was shown to be effective for improving the visual field during arthroscopy to repair rotator cuff injuries..
Introducción: Existe una amplia variedad de factores técnicos que pueden repercutir en los resultados de la reparación artroscópica del manguito rotador. Objetivo: Evaluar biomecánicamente el comportamiento de distintas alternativas técnicas para reparar el manguito rotador en un modelo animal. Material y Método: 96 tendones infraespinosos de cordero se dividieron en 8 grupos de estudio. Para pasar la sutura se usaron combinaciones de pasadores artroscópicos de distinto diámetro (1 mm, 2 mm y 3 mm de diámetro), punto de sutura a 5 y 10 mm del borde libre del tendón roto y reparación con punto simple o mattress. Se aplicó una fuerza axial progresiva, hasta el fallo de la reparación. Resultados: Menor resistencia: punto simple con pasador de 1 mm, a 5 mm del borde del tendón (100,2 N). Mayor resistencia: punto mattress con pasador de 2 mm, a 10 mm del borde del tendón (275,5N). La diferencia entre grupos fue significativa (p< 0,05). Conclusiones: Los distintos parámetros técnicos evaluados inciden significativamente en la resistencia de la reparación del manguito rotador en este modelo animal. Relevancia Clínica: El utilizar técnicas más resistentes para reparar el manguito rotador en humanos podría asociarse a una menor re-rotura del tendón y por consiguiente a un resultado funcional superior. Tipo de Estudio: Estudio Biomecánico.(AU)
The aim of this study was to investigate the influence of footprint spongialization and radiofrequency ablation on rotator cuff repair outcomes compared with an untreated group in a rat model.
We randomly assigned 189 Sprague-Dawley rats to either a spongialization, radiofrequency ablation, or untreated group. After separation of the supraspinatus tendon from the greater tubercle, the footprint was prepared by removing the cortical bone with a burr (spongialization), was prepared by ablating soft tissue with a radiofrequency ablation device, or was left unaltered (untreated). Biomechanical testing (after 7 weeks, n = 165) and histologic analysis after 1 and 7 weeks (n = 24) followed reinsertion.
The mean load to failure was 17.51 ± 4.46 N/mm(2) in the spongialization group, 15.56 ± 4.85 N/mm(2) in the radiofrequency ablation group, and 19.21 ± 5.19 N/mm(2) in the untreated group. A significant difference was found between the spongialization and radiofrequency ablation groups (P = .0409), as well as between the untreated and radiofrequency ablation groups (P = .0014). There was no significant difference between the spongialization and untreated groups (P = .2456). The mean area of fibrocartilage transition, characterized by the presence of type II collagen, was larger after 1 and 7 weeks in the spongialization group (0.57 ± 0.1 mm(2) and 0.58 ± 0.1 mm(2), respectively) and untreated group (0.51 ± 0.1 mm(2) and 0.51 ± 0.2 mm(2), respectively) than in the radiofrequency ablation group (0.11 ± 0.1 mm(2) and 0.4 ± 0.1 mm(2), respectively) with P < .05 and P < .01.
The results of this study show that radiofrequency ablation of the footprint results in a poor biomechanical and histologic outcome in an animal model. No preparation of the footprint has the same effect as spongialization.
Different techniques of footprint preparation in rotator cuff repair may influence tendon-to-bone healing.
The purpose of this study was to determine clinical and structural outcomes of arthroscopic repair of massive, contracted, immobile rotator cuff tears using interval slides.
Eleven patients who had rotator cuff tears that were irreparable using standard mobilization techniques, but were repaired using interval slides were reviewed. Patients were evaluated at mean 25.2 months (±10.3) post-operatively utilizing a standardized clinical examination and by magnetic resonance imaging (MRI).
American Shoulder and Elbow Surgeons (ASES) and Simple Shoulder Test (SST) scores improved significantly (ASES p = 0.0001; SST p = 0.0001) from pre- to post-operative. Range of motion in forward elevation and external rotation increased from pre- to post-operative, though not significantly. Strength via manual muscle testing improved on forward elevation (p = 0.001) and external rotation (p = 0.007) from pre- to post-operative. Post-operative MRI demonstrated massive re-tearing to the original size in 6 patients (55 %) and intact rotator cuffs with tissue spanning the defects in 5 (45 %) patients.
In patients with massive, contracted, immobile tears, an interval slide technique may be utilized as a salvage procedure. Arthroscopic repair of massive, contracted, immobile rotator cuff tears using interval slide techniques can lead to good clinical and satisfactory structural outcomes. LEVEL OF EVIDENCE: IV.
The purpose of this study was to compare the structural outcomes of a single-row rotator cuff repair and double-row suture bridge fixation after arthroscopic repair of a full-thickness supraspinatus rotator cuff tear.
We evaluated with diagnostic ultrasound a consecutive series of ninety shoulders in ninety patients with full-thickness supraspinatus tears at an average of 10 months (range, 6-12) after operation. A single surgeon at a single hospital performed the repairs. Inclusion criteria were full-thickness supraspinatus tears less than 25 mm in their anterior to posterior dimension. Exclusion criteria were prior operations on the shoulder, partial thickness tears, subscapularis tears, infraspinatus tears, combined supraspinatus and infraspinatus repairs and irreparable supraspinatus tears. Forty-three shoulders were repaired with single-row technique and 47 shoulders with double-row suture bridge technique. Postoperative rehabilitation was identical for both groups. Ultrasound criteria for healed repair included visualization of a tendon with normal thickness and length, and a negative compression test.
Eighty-three patients were available for ultrasound examination (40 single-row and 43 suture-bridge). Thirty-two of 40 patients (80%) with single-row repair demonstrated a healed rotator cuff repair compared to 40/43 (93%) patients with suture-bridge repair (P = .018).
Arthroscopic double-row suture bridge repair (transosseous equivalent) of an isolated supraspinatus rotator cuff tear resulted in a significantly higher tendon healing rate (as determined by ultrasound examination) when compared to arthroscopic single-row repair.
As arthroscopic rotator cuff repair techniques become ubiquitous, mastering basic surgical steps is of paramount importance
if satisfactory results are to be achieved on a consistent basis. We have learned that the critical steps in an arthroscopic
rotator cuff repair consist of (1) appropriate portal placement for optimal viewing and for manipulation of tissue and equipment;1,2 (2) tear pattern recognition, such that appropriate mobilization techniques are utilized to complete an anatomical repair
without undue tension;2 (3) rotator cuff mobilization, including supraglenoid release, subacromial space release, possible anterior interval release,
or double interval release, to include the infraspinatus and supraspinatus junction;3–5 (4) greater tuberosity preparation, in which the subchondral bone is not violated, accompanied by anchor insertion oriented
at 45° to the long axis of the humerus, to maximize pullout strength;6 (5) suture management and passage, either retrograde or antegrade, through the free edge of the tear or in a side-to-side
pattern, in which tissue is captured and coapted without sacrificing pullout strength;7,8 (6) deft knot tying such that loop and knot security are achieved while re-attaching the edge of the cuff tear to the anatomical
footprint.6
Traumatic rupture of the tendon of the subscapularis muscle was documented as an isolated lesion in the shoulders of 16 men. The injury was caused either by forceful hyperextension or external rotation of the adducted arm. The patients complained of anterior shoulder pain and weakness of the arm when it was used above and below the shoulder level. They did not experience shoulder instability. The injured shoulders exhibited increased external rotation and decreased strength of internal rotation. A simple clinical manoeuvre called the 'lift-off test', reliably diagnosed or excluded clinically relevant rupture of the subscapularis tendon. Confirmation of the clinical diagnosis was best achieved by ultrasonography or MRI, but arthrography or CT arthrography were also useful. Surgical exploration confirmed the diagnosis in every case. Repair of the ruptured tendon was technically demanding and required good exposure to identify and protect the axillary nerve.
Coracoid impingement results from encroachment on the coracohumeral space, presenting as anterior shoulder pain and clicking, particularly in forward flexion, medial rotation, and adduction. In eight shoulders in seven patients, coracohumeral decompression by excision of the lateral 1.5 cm of the coracoid with re-attachment of the conjoined tendon gave pain relief in all, and complete relief in six. This procedure is described and recommended.
Symptomatic impingement of the rotator cuff between the humeral head and the coracoid process has been studied and three varieties recognised: idiopathic, iatrogenic and traumatic. In all three the clinical findings consisted of pain in front of the shoulder, referred to the upper arm and forearm, and especially felt during forward flexion and medial rotation; the pain could be reproduced by medial rotation with the arm in 90 degrees of abduction, or by adduction with the shoulder flexed to 90 degrees. Patients were relieved of their symptoms by restoring adequate subcoracoid clearance.
Der klinischen Diagnostik kommt in der Beurteilung des Schultergelenkes eine wesentliche Bedeutung zu, aufgrund der Komplexizität des Gelenkes stellt es auch an den geübten Untersucher besondere Anforderungen. Dies gilt im besonderen auch für die Beurteilung der Rotatorenmanschettenmuskulatur. Ein wesentlicher Aspekt ist der enge Bezug zur Impingementpathologie, da häufig der Rotatorenmanschettendefekt Ursache oder Folge des Impingementsyndroms ist.
Impingement on the tendinous portion of the rotator cuff by the coracoacromial ligament and the anterior third of the acromion is responsible for a characteristic syndrome of disability of the shoulder. A characteristic proliferative spur and ridge has been noted on the anterior lip and undersurface of the anterior process of the acromion and this area may also show erosion and eburnation. The treatment of the impingement is to remove the anterior edge and undersurface of the anterior part of the acromion with the attached coracoacromial ligament. The impingement may also involve the tendon of the long head of the biceps and if it does, it is best to decompress the tendon and remove any osteophytes which may be in its groove, but to avoid transplanting the biceps tendon if possible. Hypertrophic lipping at the acromio-clavicular joint may impinge on the supraspinatus tendon when the arm is in abduction and, if the lip is prominent, this joint should be resected. These are the principles of anterior acromioplasty.
1. The results of operation in sixty-three patients with rupture of the rotator cuff of the shoulder have been reviewed.
2. In seventeen patients the classical delto-pectoral route was found to give poor access and mediocre results.
3. In forty-six patients a superior approach along the supraspinatus fossa and through the divided acromion process was found to give excellent access and to permit lateral advancement of the supraspinatus muscle in order to enable wide gaps to be closed. With this improved surgical access the proportion of good results has been doubled.
4. It is suggested that when a case of rupture of the cuff, confirmed by arthrography, fails to respond to physiotherapy, operative repair should be undertaken.
Soft tissue impingement under the coracoid process has recently been identified as a cause of painful shoulder disability. In this study the normal space between the humeral head and the coracoid process in two functional positions of the arm was measured in an attempt to delineate anatomic risk factors predisposing to subcoracoid impingement. Forty-seven normal shoulders were studied by computerized tomography (CT) in adduction, 20 additionally in forward flexion/internal rotation, which is the position most frequently causing subcoracoid impingement. The distance between the humeral head and the coracoid tip averaged 8.7 mm for the adducted arm and 6.8 mm for the flexed arm. Modifications of the coracohumeral relationship were found to affect the subcoracoid clearance roughly 1.5 times more in flexion than with arm at the side. Subcoracoid impingement appeared particularly likely during forward flexion of a shoulder with a coracoid tip close to the scapular neck and projecting far laterally.
Purpose: This study was performed to evaluate 2 arthroscopic techniques for rotator cuff repair used by 1 surgeon for more than 12 years. The main objective of this study was to test the reliability of these arthroscopic repair techniques not only using clinical assessment during the follow-up, but through observation of the healing process of the tendons during the arthroscopic removal of the staples in our first group of patients. Type of Study: This study was a before/after trial. Methods: We present the results of arthroscopic repair of full-thickness rotator cuff tears in 100 patients. In group I, 35 patients had staple fixation, and in group II, 65 patients had side-to-side suture and anchor repair. Follow-up ranged from 2 to 14 years. All shoulders were evaluated using the UCLA rating scale. Shoulders repaired with staples (group I) were evaluated arthroscopically at staple removal. Arthroscopic subacromial decompression was performed in 26 of the 35 patients in group I and in 65 of the 65 patients in group II; 58 patients in group II had concomitant resection of distal clavicle. Results: In group I, 22 patients (63%) had excellent results (UCLA scores, 34-35), 7 (20%) had good results (UCLA scores, 28-33), 4 (11%) had fair results (UCLA scores, 21-27), and 2 (6%) of the patients had poor results (UCLA scores, 0-20). In group II, 47 patients (72%) had excellent results (UCLA scores, 34-35), 12 (19%) had good results (UCLA scores, 28-33), 2 (3%) had fair results (UCLA scores, 21-27), and 4 (6%) of the patients had poor results (UCLA scores, 0-20). Conclusions: Patients with well-healed rotator cuff tendons had satisfactory postoperative results and better overall functional results. The arthroscopic techniques for rotator cuff repair achieve results comparable to the results of traditional open repair. However, these technically demanding arthroscopic procedures require advanced arthroscopic skills and have a steep learning curve.
Arthroscopic repair of rotator cuff tears is now possible. By using the biomechanical principles of margin convergenceand the balance of force couples, even large cuff defects can be repaired. Suture anchors are particularly suitable for arthroscopic repairs, and a corkscrew anchor design lends itself to a trans-tendon approach
Careful physical examination and supportive three-dimensional radiographs allow for an accurate detection of isolated subscapularis tendon tears. Prompt surgical treatment usually results in a satisfactory outcome, whereas a delay in treatment may result in an unsatisfactory outcome. Although recognition of isolated supraspinatus tendon tears is not difficult, attention to the technical details of surgical repair can only improve the reliability of such surgery.
Tears of the subscapularis tendon are infrequent though not rare, and diagnosis can be difficult. Surgical treatment is a technical challenge, though timely repair can result in a good outcome.
(C) Williams & Wilkins 1994. All Rights Reserved.
Despite being the largest rotator cuff tendon of the shoulder, the function and clinical relevance of subscapularis pathology has been largely ignored in the literature. Although more recent studies have focused on subscapularis tears, all have reported on techniques of open repair. The advent of arthroscopy and arthroscopic repair techniques has opened new frontiers for the diagnosis and repair of torn rotator cuff tendons, including the subscapularis. In this article, the authors review the senior author's surgical rationale, technique, and preliminary results of arthroscopic subscapularis repair.
The macroscopic anatomy and the architecture of the collagen fiber bundles were studied in the joint capsules of 43 cadaver shoulders. All the specimens were transilluminoted by polarized light after preparation by Spalteholz' technique. Areas of high-fiber density and complex structure were examined histologically. The macroscopically recognizable ligaments are composed of collagen fiber bundles in several layers of differing thickness and orientation. A simple pattern of radial and circular fibers is found only in the relatively thin posterior capsule. A complex pattern of cross-linking was visible in the superior capsule, and a system of fiber bundles spirally crossing each other was present in the anterior/inferior capsule. The examination under polarized light revealed a continuous transition between the ligamentous reinforcements at the anterior inferior capsule, which radiated obliquely from the glenoid rim and varied greatly in form and orientation. The complicated structure of the joint capsule would suggest that the capsular cylinder has to be regarded as a functional entity and that the current biomechanical concepts must be modified if we want to understand its stabilizing effect. The structural features of the superior capsule present new insight about the pathogenesis of rotator cuff tearing, which can develop as a result of shearing stress between the capsular and tendinous layers.
The anterior or subcoracoïd impingement is often mentioned but remains unprecise as far as clinical, radiological or even anatomical lesion are concerned. The purpose of our work was to study the different factors influencing the subcoracoïd space in case of cuff tear.
Our study was based on 206 shoulders operated for full-thickness rotator cuff tear. The SubCoracoïd Space (SPS), measured in millimeters on pre-operative arthro-CT-scan, was defined by the shortest distance between the coracoïd process and the humeral head. Muscular statement of the rotator cuff componants was graded according to Goutallier's and Bernageau's classification. According to literature data, we chose "6 mm" value as an inferior limit for normality. Shoulders were dispatched into three groups: group 1 was composed of supraspinatus +/- infraspinatus tears (59 cases), group 2 was composed of isolated lesions of the subscapularis (57 cases) and group 3 was composed of large cuff tears (supraspinatus +/- infraspinatus) involving also the subscapularis (90 cases).
There was a statistically significant relationship between SCS narrowing, duration of symptoms and the non-traumatic onset. When there was no subscapularis lesion (group 1) the mean SCS was 9 +/- 2 mm, in 3 cases the SCS was inferior to 6 mm. In group 2 (isolated lesion of the subscapularis), the results were similar with 9 mm as an average and 3.5 p. 100 SCS inferior to 6 mm. On the contrary, in group 3 we found the major percentage of SCS inferior to 6 mm (27 p. 100) with an average of 7.7 +/- 3.5 mm. The long head of the biceps had no influence on the SCS. There was a strong statistically significant relationship between SCS size and fatty degeneration of the subscapularis muscle (p < 10-4) and infraspinatus muscle (p = 0.0004). Eventually, there was a statistically significant correlation between the subcoracoïd space and the sub acromial space.
Measurements of the SCS in isolated lesions of the subscapularis show that the coracoïd process is not the mechanical factor responsible for tendon rupture. SCS narrowing is the consequence of a large cuff tear involving both the subscapularis and the infraspinatus tendon. Subscapularis tear is a necessary but not a sufficient condition by itself for SBS narrowing. Complete tear of the infraspinatus tendon and above all the muscular degeneration of the infraspinatus muscle is the other necessary condition for SCS narrowing. The horizontal control of the humeral head depends on subscapularis-infraspinatus muscular balance control. According to Patte's hypothesis SCS narrowing corresponds to an horizontal anterior translation of the humeral head due to fatty degeneration of subscapularis and infraspinatus muscle.
This Classic Article is a reprint of the original work by John Gregory Smith, Pathological Appearances of Seven Cases of Injury
of the Shoulder-Joint: With Remarks. An accompanying biographical sketch of John Gregory Smith, FRCS is available at DOI 10.1007/s11999-010-1232-9. The Classic Article is ©1834 and is reprinted from Smith JG. Pathological appearances of seven cases of injury of the shoulder-joint:
with remarks. London Medical Gazette. 1834;14:280–285.
In sixteen patients with massive tears of the rotator cuff of the shoulder, bridging of the defect with a freeze-dried graft of a rotator cuff from a cadaver produced a satisfactory repair in all cases. A good or excellent functional result was obtained in all but two patients, with a definite decrease or absence of nocturnal pain in all sixteen. The operative technique includes avoidance of a complete acromionectomy and an adequate suture of the deltoid muscle to the acromion after an acromioplasty.
Twelve shoulders with known massive rotator cuff tears were imaged fluoroscopically. The observed kinematic patterns were correlated with the known locations of the rotator cuff tears. Three kinematic patterns emerged: Type I, stable fulcrum kinematics associated with tears of the superior rotator cuff (supraspinatus and a portion of the infraspinatus); Type II, unstable fulcrum kinematics associated with tears that involved virtually all of the superior and posterior rotator cuff; and Type III, captured fulcrum kinematics associated with massive tears that involved the supraspinatus, a major portion of the posterior rotator cuff, and a major portion of the subscapularis. In Type III, an "awning effect" of the acromion was observed to influence active motion. Based on the recorded kinematic patterns, a biomechanical model was developed comparing the rotator cuff tear to a suspension bridge (loaded cable). A biomechanical analysis of forces acting on the rotator cuff according to this model yielded data that supported the contention that certain rotator cuff tears in older individuals may be adequately treated with debridement and decompression, without repair.
We investigated the structure of the myotendinous rotator cuff in thirty-two grossly intact cuffs from thirty fresh cadavera of subjects who had been seventeen to seventy-two years old at the time of death. We studied the gross anatomy of the capsule and ligaments of the cuff, as well as histological sections of the tendons of the subscapularis, supraspinatus, and infraspinatus muscles. The tendons were found to splay out and interdigitate to form a common, continuous insertion on the humerus. The biceps tendon was ensheathed by interwoven fibers derived from the subscapularis and supraspinatus tendons. The anterior margin and bursal surface of the supraspinatus tendon were enveloped by a thick sheet of fibrous tissue derived from the coracohumeral ligament. Fibers from the coracohumeral and glenohumeral ligaments were found concentrated in a plane between the capsule and the tendons of the cuff. Microscopically, in the region of the supraspinatus and infraspinatus tendons, the cuff was composed of five layers defined by the attachments and orientations of the fibrous elements in each of these layers.
Thirty-one shoulders in eighteen cadavera were dissected to allow study of the neurovascular anatomy of the rotator cuff and to help determine the limits of mobilization of the cuff for the repair of chronic massive retracted tears. The dissection demonstrated the diameter, length, and relationships of the suprascapular nerve and its branches and made clear the dangers of extensive mobilization and advancement of the supraspinatus and infraspinatus muscles. The suprascapular nerve ran an oblique course across the supraspinatus fossa, was relatively fixed on the floor of the fossa, and was tethered underneath the transverse scapular ligament. In twenty-six (84 per cent) of the thirty-one shoulders, there were no more than two motor branches to the supraspinatus muscle, and the first was always the larger of the two. In twenty-six (84 per cent) of the thirty-one shoulders, the first motor branch originated underneath the transverse scapular ligament or just distal to it. In one shoulder (3 per cent), the first motor branch passed over the ligament. The average distance from the origin of the long tendon of the biceps to the motor branches of the supraspinatus was three centimeters. In fifteen (48 per cent) of the thirty-one shoulders, the infraspinatus muscle had three or four motor branches of the same size. The average distance from the posterior rim of the glenoid to the motor branches of the infraspinatus muscle was two centimeters. The motor branches to the supraspinatus muscle were fewer, usually smaller, and significantly shorter than those to the infraspinatus muscle. The standard anterosuperior approach allowed only one centimeter of lateral advancement of either tendon and limited the ability of the surgeon to dissect safely beyond the neurovascular pedicle. The advancement technique of Debeyre et al., or a modification of that technique, permitted lateral advancement of each muscle of as much as three centimeters and was limited by tension in the motor branches of the suprascapular nerve. In some situations, the safe limit of advancement may be even less. We concluded that lateral advancement of the rotator cuff is limited anatomically and may place the neurovascular structures at risk.
Subcoracoid impingement is a relatively obscure syndrome. Guided by studies conducted by Gerber and Patte since 1985, the authors began to select cases of periarticular disease of the shoulder in which there was clinical evidence of involvement of the subcoracoid space. These patients underwent repeated clinical examination, radiographic examination according to Bernageau, CT scan, and Arthro-CT. All patients were tested with a novocaine infiltration into the subcoracoid space. This paper contains a precise diagnostic protocol that has evolved from the studies conducted by Gerber and Patte. Of the 23 patients selected, 3 were advised to undergo surgical widening of the subcoracoid space, consisting of resection of the coracoacromial and coracohumeral ligaments and special, reductive coracoidplasty.
We evaluated the results of 105 operative repairs of tears of the rotator cuff of the shoulder in eighty-nine patients at an average of five years postoperatively. We correlated the functional result with the integrity of the cuff, as determined by ultrasonography. Eighty per cent of the repairs of a tear involving only the supraspinatus tendon were intact at the time of the most recent follow-up, while more than 50 per cent of the repairs of a tear involving more than the supraspinatus tendon had a recurrent defect. Older patients and patients in whom a larger tear had been repaired had a greater prevalence of recurrent defects. At the time of the most recent follow-up, most of the patients were more comfortable and were satisfied with the result of the repair, even when they had sonographic evidence of a recurrent defect. The shoulders in which the repaired cuff was intact at the time of follow-up had better function during activities of daily living and a better range of active flexion (129 +/- 20 degrees compared with 71 +/- 41 degrees) compared with the shoulders that had a large recurrent defect. Similar correlations were noted for the range of active external and internal rotation and for strength of flexion, abduction, and internal rotation. In the shoulders in which the cuff was not intact, the degree of functional loss was related to the size of the recurrent defect.(ABSTRACT TRUNCATED AT 250 WORDS)
Ten patients with painful, massive (greater than 5 cm), complete rotator cuff tears involving primarily the supraspinatus were treated with arthroscopic acromioplasty and rotator cuff debridement. All patients except one had normal active motion and strength preoperatively. All patients had roentgenographically normal acromiohumeral distance and an anterior-inferior acromial osteophyte. The goal was to obtain pain relief without loss of motion of strength. This was accomplished in all patients. This study shows that normal shoulder function is possible with a massive unrepaired tear of the rotator cuff. Normal function in the face of an unrepaired cuff tear can occur only if there is a balance of two important force couples, one in the coronal plane and the other in the transverse plane. This balance depends upon the functional integrity of the anterior cuff, the posterior cuff, and the deltoid. In patients whose cuff tears satisfy these anatomic and biomechanical criteria, the achievement of pain relief through arthroscopic debridement and decompression seems to be all that is necessary for normal pain-free function.
Researchers must gather all anatomic and clinical information and evaluate the results of various imaging techniques and operative procedures if more is to be learned about anteromedial subcoracoid or coracohumeral impingement. Although the impingement syndrome constitutes an anatomic and clinical entity, more must be learned about the pathogenesis to arrive at well-founded surgical solutions.
Arthroscopic acromioplasty was done for a lesion of the rotator cuff in 165 patients: 100 who had stage-II impingement syndrome (no actual tear of the rotator cuff) (group 1), forty who had a partial tear (group 2), and twenty-five who had a full-thickness tear (group 3). The operation consisted of acromioplasty, resection of the coracoacromial ligament and subacromial bursa, and removal of osteophytes, when present, near the inferior aspect of the acromioclavicular joint. In the patients who had a partial or complete tear, minimum debridement of the rotator cuff also was performed. In group 1, eighty-six patients (eighty-nine shoulders) were available for review at a minimum follow-up to two years (average, 31.2 months). The preoperative ratings for pain, activities of daily living, work, and sports improved markedly in eighty-one patients postoperatively. The most common findings at operation were proliferative subacromial bursitis and an acromial protuberance. Two complications were recorded. Seven patients had a subsequent open operation on the shoulder. In group 2, the average follow-up was 28.9 months (range, twenty-four to forty-eight months). Of the forty patients, thirty-three had a major improvement in the ratings for pain, activities of daily living, work, and sports. One complication, transient palsy of the lateral femoral cutaneous nerve, was noted. Two patients who had an unsatisfactory result had a second operation: one, open acromioplasty and the other, repair of the rotator cuff. In group 3, the average follow-up was 30.8 months (range, twenty-four to fifty-five months). There were fourteen satisfactory and eleven unsatisfactory results. Of the twenty-five patients, seven later had open repair of the rotator cuff, and six had a satisfactory result from that procedure. No complications were recorded. It was concluded that arthroscopic acromioplasty is effective in the treatment of isolated stage-II impingement and partial tears of the rotator cuff. Arthroscopic treatment of complete tears produced over-all results that were inferior to those of traditional open repair. Arthroscopic subacromial decompression cannot be supported as treatment for complete tears of the rotator cuff.
Thirty-one patients who were unable to abduct the involved arm after reduction of a primary anterior dislocation of the glenohumeral joint were found to have a ruptured rotator cuff. All of the patients were more than thirty-five years old. Twenty-nine of them were initially presumed to have had an injury to the axillary nerve, although this injury was confirmed in only four of the twenty patients who had electrodiagnostic studies. In eight patients, the subscapularis tendon and anterior part of the capsule had ruptured from the lesser tuberosity. Recurrent instability developed in all eight patients, and repair of these structures alone was successful in restoring stability. The association between primary anterior dislocation of the glenohumeral joint and rupture of the rotator cuff in the older patient who cannot abduct the arm after reduction is poorly appreciated, as it is often missed. In our series of such patients, the incidence of injury to the axillary nerve was 7.8 per cent, as compared with 100 per cent for rupture of the rotator cuff. However, the comparative rates of occurrence of these two entities in older patients who have an anterior dislocation have not been determined.
We evaluated the results of arthroscopic subacromial decompression according to the degree of rotator cuff tear in 71 patients, available for follow-up for at least 1 year (average 19 months). Of the patients with stage II disease, 82% were satisfied regardless of whether they had no rotator cuff tear (nine of 11) or had a partial tear (28 of 34) of the rotator cuff. Of patients with stage III disease (complete rotator cuff tear), 88% (23 of 26) were satisfied. An acceptable objective UCLA shoulder rating greater than or equal to 28 points was seen in 82% (nine of 11) of the patients without a rotator cuff tear, 76% (26 of 34) with a partial tear, and 77% (20 of 26) with a complete tear. All four of the patients with complete tears less than 1 cm obtained excellent results. Three of the six failures were in patients with complete tears who had a narrowed acromial-humeral distance of less than 7 mm. The average UCLA pain score showed significant improvement from 2.8 (constant pain) to 8.6 (occasional pain) at 1-2 years postoperatively. The function, strength, and active forward flexion scores also increased at 1-2 years from their preoperative values. The overall patient satisfaction rate of 85% and the objective success rate of 77% are within the range of that seen with open rotator cuff repair.
Rotator cuff injuries, especially in athletes, can be very disabling. A case of an isolated rupture of the subscapularis tendon in an arm wrestler is reported. Preoperative arthrogram and CT scan with intraoperative pictures are used to illustrate the pathology. Recommendation for treatment is surgical repair.
In fifty patients who had fifty tears of the rotator cuff that had been repaired, we correlated the preoperative findings by history, physical examination, and radiography with the operative findings, the difficulty of the repair, and the results after an average follow-up of 3.5 years. The results, which were rated on the basis of pain, function, range of motion, strength, and satisfaction of the patient, were satisfactory in 84 per cent and unsatisfactory in 16 per cent. The correlations of the preoperative findings with the results showed that pain and functional impairment, the primary indications for repair, were significantly relieved. The longer the duration of pain was preoperatively, the larger the cuff tear and the more difficult the repair were. The strength of abduction and of external rotation before repair was of prognostic value: the greater the weakness, the poorer the result. The poorest results were in patients with strength ratings of grade 3 or less. Limitation of active motion preoperatively was also of prognostic value: in patients who were unable to abduct the shoulder beyond 100 degrees preoperatively, there was an increased risk of a poor result. An acromiohumeral distance of seven millimeters or less (measured on the anteroposterior radiograph) suggested a larger tear and the likelihood that after repair there would be less strength in flexion, less active motion, and lower scores. Single or double-contrast arthrography was not consistently accurate in estimating the size of the tear. After so-called watertight repair and anterior acromioplasty, successful results can be anticipated in a high percentage of patients.
Soft tissue impingement under the coracoid process has recently been identified as a cause of painful shoulder disability. In this study the normal space between the humeral head and the coracoid process in two functional positions of the arm was measured in an attempt to delineate anatomic risk factors predisposing to subcoracoid impingement. Forty-seven normal shoulders were studied by computerized tomography (CT) in adduction, 20 additionally in forward flexion/internal rotation, which is the position most frequently causing subcoracoid impingement. The distance between the humeral head and the coracoid tip averaged 8.7 mm for the adducted arm and 6.8 mm for the flexed arm. Modifications of the coracohumeral relationship were found to affect the subcoracoid clearance roughly 1.5 times more in flexion than with arm at the side. Subcoracoid impingement appeared particularly likely during forward flexion of a shoulder with a coracoid tip close to the scapular neck and projecting far laterally.
Rotator cuff disease is a common and important source of shoulder symptoms. The cuff mechanism functions not only to stabilize the shoulder but also to provide power and perhaps assist with the maintenance of joint nutrition. The pathogenesis of rotator cuff disease is associated with aging; repetitive use or injury; tendon hypovascularity; and, seemingly most important, subacromial tendon impingement. There is a large spectrum of pathological changes within this disease category. Non-operative therapy may be effective, but it is not as consistently successful as was formerly believed. Early surgical treatment should be considered for the rare acute injury that produces a large rotator-cuff defect and loss of active abduction. Long-term non-operative treatment is desirable for almost all patients with tendon inflammation. When surgical treatment is undertaken, an anterosuperior approach is most useful. Anterior acromioplasty should always be considered. Resection of the distal part of the clavicle or bicipital tenodesis is indicated only when acromioclavicular arthritis or substantial wear or instability of the biceps tendon is present. The size and shape of the tendon tears vary greatly. The most direct and simple repair technique seems to be the best - progressing from direct tendon repair to repair to bone, to transposition of local tissue, to grafting. Postoperative support should vary according to need. Physiotherapy after surgery seems to be quite important. Failures of surgical repair that are associated with rotator cuff retearing have a fair to poor prognosis after a second tendon repair. Advanced rotator-cuff disease may rarely be associated with the development of severe glenohumeral arthritis resulting in a combination of lesions that is very difficult to treat.
Impingement lesions are considered in three progressive stages: I, edema and hemorrhage; II, fibrosis and tendinitis; III, tears of the rotator cuff, biceps ruptures, and bone changes. The physical findings in all of these stages are similar, accounting for some of the misconceptions about tears of the rotator cuff. The 'impingement test' identifies these lesions. Arthrography is the most reliable method of identifying complete-thickness tears from other impingement lesions. Further observations confirm that impingement occurs anteriorly, not laterally. It is thought that most supraspinatus and biceps lesions are due to impingement wear, usually caused in part by variations in the shape and slope of the acromion. When these tendons rupture, impingement may be escalated, because the head is allowed to migrate upward. Anterior acromioplasty is used routinely when tears of the rotator cuff are repaired, to decompress the supraspinatus from continuing wear. It is also used for chronic disability associated with incomplete tears but only occasionally in patients younger than 40 years of age. The approach offered by an anterior acromioplasty for repairing the rotator cuff offers three advantages over lateral acromionectomy: (1) less deltoid detachment; (2) better exposure of the supraspinatus; and (3) better decompression of the supraspinatus against continuing impingement. Small, unfused anterior acromial epiphyses are excised, whereas larger, unfused centers are tilted up and closed by curettage and local bone grafts, and internally fixed with screws or threaded wires.
Tears of the rotator cuff can be very challenging for the surgeon. He should be aware of the variations in the pathologic lesions that can be encountered and should understand the functions of the cuff-capsule mechanisms so that deficiencies can be appropriately defined and treated. A definite diagnosis, based on the history, physical examination, roentgenography, and arthrography, should be made. In some patients with acute tears of the rotator cuff, early operative treatment is warranted. Chronic cuff disease is often treated conservatively. When operative invervention is justified, the anterior or anterosuperior surgical approach is most useful, and the classic plastic surgery flap techniques provide a model for planning and executing the repair. Postoperative external support and the physical therapy program should be tailored to the complexity and the security of the cuff repair.
Subscapularis transposition into a supraspinatus or supraspinatus and infraspinatus rotator cuff defect has been overlooked as a method of tendon repair. The surgical technique for this type of repair, with or without the concomitant use of a glenohumeral resurfacing prosthesis, is described. Postoperatively, the extremity is supported in a position that does not allow stress to be placed on a repair until healing has occurred. Generally, physical therapy is begun early and continued for many months. In the present series, satisfactory relief of pain was achieved in 22 of the 26 patients. Active abduction in the plane of the scapula averaged 120 degrees for patients with rotator cuffs repair and prosthetic replacement and 130 degrees for those with rotator cuff repair alone. Twelve patients gained more than 30 degrees active abduction, and four lost this amount of motion, or greater, as compared with preoperative capabilities. In two of the 26 patients, the rotator cuff repair was completely disrupted during the acute postoperative period. Twenty-five of the 26 patients were satisfied with the surgical procedure. This type of repair seems to be a secure repair, bring healthy tendon tissue into an area of tendon degeneration and loss of tissue substance. As such, it satisfies the basic surgical principles of achieving repair with healthy tissue that is not under tension. The results compare favorably with those reported in the literature on rotator cuff repair and further suggest that this technique is an acceptable alternative for repairing large or massive rotator cuff tears that have tendon substance loss. However, this technique should not be used for smaller tears, for which more simple techniques are more adequate, because if a retear occurs during the postoperative period, the cuff detect might be quite large, with significant pain postoperatively and functional limitations resulting.
The goal of this retrospective study is to describe the different anatomic lesions of the subscapularis and to precise the diagnostic value of the clinical and imaging tests.
Twenty-one cases of isolated tear of the subscapularis were operated on between 1989 and 1992. Affecting both sex, this lesion happens in younger patients than the rotator cuff tear concerning supra or infra-spinatus. The onset was most often traumatic but not specific. Four patients had no traumatic history.
In 16 cases, the complaint was an unspecific chronic painful shoulder. The Jobe test was positive in 12 cases. The lift-off test was positive in 9 cases. Arthrography showed extravasation of dye into the subacromial bursa in 11 cases. Subscapularis lesion was suspected with the presence of dye spot on the lesser tuberosity on the A.P. view in external rotation (18 cases). Arthro-CT-scan was diagnostic in 12 cases, revealing dye spot touching the lesser tuberosity. At surgery, 3 types of lesions were found: complete ruptures or ruptures concerning the superior two-thirds of the tendon and letting intact the inferior muscular third (15 cases): partial superior lesions (5 cases) and a muscular tear of the inferior two-thirds. The long head of the biceps was dislocated in 5 cases, subluxated in 5 cases, ruptured in 3 cases and normal in 8 cases.
The mechanisms of these lesions are probably different. The most common mechanism is traumatic but 4 patients had no traumatic injury. Degenerative changes of the tendon or subcoracoid impingement are also evocated. Arthrography permits a good screening but arthro-CT-scan is the most accurate to detect the lesion. Presence of dye touching the lesser tuberosity is a specific sign of the subscapularis lesion.
This study analyzes the results of a previously unreported technique of reconstruction for the massive irreparable rotator cuff tear. The technique involves repair of the margins of the tear to restore the force couples and "suspension bridge" system of force transmission in the shoulder. Complete coverage of the defect was not considered to be essential as long as the normal mechanics of the shoulder were restored and the rotator cuff tear was converted to a "functional cuff tear." This procedure was performed on 14 patients. Improvement in function was dramatic. Active elevation (elevation denotes the plane of motion midway between the planes of shoulder abduction and shoulder flexion; elevation is reported because it is the most functional plane in which to raise the arm) improved by 90.8 degrees: from a preoperative average of 59.6 degrees to a postoperative average of 150.4 degrees. Strength improved an average of 2.3 grades on a 0-to-5-point scale. The average score on the UCLA Shoulder Rating Scale improved from a preoperative value of 9.8 to a postoperative value of 27.6. All but one patient was very satisfied with his or her result. The authors are of the opinion that this technique is preferable to other reconstructive techniques, such as tendon transposition, that emphasize coverage of the defect at the expense of destroying the normal mechanics of the shoulder. The authors suggest that partial repair of massive irreparable rotator cuff tears should supplant tendon transposition as the procedure of choice for this condition.
Twenty fresh frozen cadaver shoulders were dissected in order to study the rotator cable-crescent complex. The rotator crescent is a term that we have used to describe the thin, crescent-shaped sheet of rotator cuff comprising the distal portions of the supraspinatus and infraspinatus insertions. The crescent was found to be bounded on its proximal margin by a thick bundle of fibers that we have called the rotator cable. This cable-crescent configuration was found to consistently span the insertions of supraspinatus and infraspinatus tendons. The dimensions of the rotator cable and crescent were measured by a digital micrometer. The rotator cable was found to be a very substantial structure, averaging 2.59 times the thickness of the rotator crescent that it surrounded. This anatomic study supports the concepts of stress-shielding of the rotator crescent by the stout rotator cable and stress transfer by this loaded cable system.
Clinical results of arthroscopic rotator cuff debridement and decompression in 25 patients are presented. Additionally, a fluoroscopic study of 14 patients with known massive rotator cuff tears reveals four kinematic patterns in patients with major cuff deficiencies. Biomechanical models are used to support further the clinical impression that certain rotator cuff tears are amenable to arthroscopic debridement and decompression without repair. Specific indications for arthroscopic debridement and decompression are developed and presented.